CJEM Articles: headache
Displaying 1-6 of 6 results
-
May
2010
12
3
Benoit Bailey, Evelyne Doyon-Trottier, Sergio Manzano
-
November
2009
11
6
Anne-Maree Kelly, Catherine M. Clement, Debra Eagles, Ian G. Stiell, Jamie Brehaut, Jeffrey J. Perry, Suzanne Mason
Objective: Patients with acute headache often undergo com puted tomography (CT) followed by a lumbar puncture to rule out subarachnoid hemorrhage. Our international study exam ined current practice, the perceived need for a clinical deci sion rule for acute headache and the required sensitivity for such a rule.
Methods: We approached 2100 emergency physicians from 4 countries (Australia, Canada, the United Kingdom and the United States) to participate in our survey by sampling the membership of their emergency associations. We used a modified Dillman technique with 3-5 notifications and a prenotification letter employing a combination of electronic mail and postal mail. Physicians were questioned about neu rologically intact patients who presented with headache. Analysis included both descriptive statistics for the entire sample and stratification by country.
Results: The total response rate was 54.7% (1149/2100). Respondents were primarily male (75.5%), with a mean age of 42.5 years and a mean 12.3 years of emergency depart ment (ED) experience. Of the physicians who responded, 49.5% thought all acute headache patients should be investi gated with CT and 57.4% felt CT should always be followed by lumbar puncture. Of the respondents, 95.7% reported they would consider using a clinical decision rule for patients with acute headache to rule out subarachnoid hemorrhage. Respondents deemed the median sensitivity required by such a rule to be 99% (interquartile range 98%-99%). Approxi mately 1 in 5 physicians suggested that 100% sensitivity was required.
Conclusion: Emergency physicians report that they would welcome a clinical decision rule for headache that would determine which patients require costly or invasive tests to rule out subarachnoid hemorrhage. The required sensitivity of such a rule was realistic. These results will inform and inspire the development of clinical decision rules for acute headache in the ED.
-
September
2004
6
5
Carin M. Olson, Klaus B. Shuler, Leonard R. Frank, Salma F. Gharib
Background: Magnesium deficiency may play a role in the pathogenesis of migraines and other headaches. Studies in outpatient clinics have found that magnesium administered intravenously (IV) reduces headache pain. We investigated the effectiveness of IV magnesium in patients with acute benign headache who presented to the emergency department (ED).
Methods: This randomized double-blind placebo-controlled trial compared 2 g of IV magnesium versus placebo for the treatment of patients with acute benign headache who presented to the EDs of two teaching hospitals. Pre- and post-treatment pain scores were measured on a 100-mm visual analog pain scale.
Results: Forty-two patients were randomized, 21 in each treatment group. Treatment groups had similar baseline characteristics. After treatment, placebo recipients reported an 8-mm median improvement in pain, and magnesium recipients had a 3-mm improvement (p = 0.63). We found no statistically significant difference between groups for any secondary outcomes; however, the patients who received magnesium had significantly (p = 0.03) more side effects than did those in the placebo group.
Conclusions: We found no benefit to using IV magnesium to treat patients with acute benign headache who present to the ED.
-
January
2004
6
1
John Rizos, Michael Wansbrough
-
September
2002
4
5
Alena Spacek, George Wells, Ian Stiell, Jeffrey J. Perry
Objectives: This study evaluated the incidence of subarachnoid hemorrhage (SAH) and the use of computed tomography (CT) and lumbar puncture (LP) in a cohort of emergency department (ED) patients with acute headache.
Methods: Health records from a tertiary care ED were used to identify all patients over 15 years of age who presented with headache over a 10-month period. Patients were excluded if they had been referred with confirmed SAH or if they had recurrent headache, head trauma, decreased level of consciousness or new neurologic deficits. Outcome measures included ED diagnosis, use of CT or LP, and ED length of stay. Analysis included descriptive statistics, 95% confidence intervals (CIs) and analysis of variance for length of stay.
Results: The mean age of the 891 patients was 41.9 years. Ten (1.1%) of the patients had SAH, 313 (35.1%) underwent CT, and 85 (9.5%) underwent LP. Only 9 (2.9%) of the CT scans and 2 (2.4%) of the LPs were positive for SAH. Of the 296 patients with normal CT results, 232 (78.4%) did not undergo subsequent LP. The mean length of stay was 4.0 hours (95% CI, 3.8-4.1) if no diagnostic testing was performed, 5.0 hours (95% CI, 4.7-5.4) if CT was performed and 7.1 hours (95% CI, 6.3-7.9) if LP was performed (p = 0.001).
Conclusions: Diagnostic testing was associated with substantially prolonged lengths of stay. CT and LP had low diagnostic yields, which suggests the need for a clinical decision rule to rule out SAH in ED patients with acute headache. -
April
1999
1
1
Cathy Metcalfe, Edward C. Dillon, Grant D. Innes, Iain MacPhail, Min Gao
Objective: To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment.
Methods: Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double- blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment).
Results: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At followup, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005).
Conclusions: Migraine recurrence is common after “successful” ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.
